Pediatric Discharge Summary
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Discharge Summary As you begin, state that you want the transcriptionist to use the Pediatric Discharge Summary Template for the dictation ADMISSION DATE: DISCHARGE DATE: ADMISSION DIAGNOSES: What you thought diagnosis was at admission based upon information available at that time.. DISCHARGE DIAGNOSIS ASSESSMENT: One line summary DISCHARGE TO: Usually home, but sometimes a facility DISCHARGE CONDITION: Should be Good or Stable if they are going home DISCHARGE MEDICATIONS: Include doses, frequency and length of therapy DISCHARGE INSTRUCTIONS: You must list them out, everything you checked or wrote on the discharge form– do not say “as listed in the medical record.” PENDING LABS: List all labs that are pending at the time of dictation..
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